The ED – a Place to Identify Abuse
Older adults are commonly victims of elder abuse, neglect, and exploitation, with 5-10% of community-dwelling seniors experiencing elder mistreatment each year. This mistreatment is associated with adverse health outcomes, including hospitalization, nursing home placement, and significantly increased mortality. Unfortunately, it is dramatically under-recognized, with as few as 1 in 24 cases reported to the authorities. An emergency department (ED) visit offers a critical opportunity to identify elder mistreatment. Assessment by medical providers for injury or illness may be the only time a victimized older adult leaves their home. Victims of elder mistreatment seek emergency care more frequently than other older adults and are less likely to receive routine care from a primary outpatient provider. Further, the potential for identifying elder abuse in the ED is likely higher than in other healthcare settings because ED visits are typically prolonged, involving interaction with providers from multiple disciplines.
Unfortunately, evidence suggests that, despite the profound impact identifying elder mistreatment can have on a patient’s life, emergency providers currently very rarely recognize or report it. This is likely due to a combination of lack of both education regarding the scope of elder abuse and formal training in identifying signs of abuse, uncertainty about the appropriate steps to take after identification, and doubts about the effectiveness of interventions. Senior-friendly EDs should strive to improve this through screening and intervention protocols.
Screening and Intervention Protocols
Several screening tools have been developed to assist in elder mistreatment detection, but many are lengthy, and few have been validated in primary care settings. The Elder Abuse Suspicion Index (EASI) is a short screening instrument that is easy to use in the ED and has been validated for cognitively intact patients in family practice and ambulatory care settings. This is available at: http://www.nicenet.ca/tools-easi-elder-abuse-suspicion-index.
Research supported by the U.S. National Institute of Justice to develop and validate an ED-specific screening tool for elder abuse is currently ongoing.
ED leaders should support providers with comprehensive written protocols on appropriate additional evaluation, management, and reporting for patients who screen positive or for those whom providers suspect might be victims. When possible, a multi-disciplinary approach involving social work is ideal to optimize care and ensure safety for these patients. In many but not all jurisdictions, ED providers are mandatory reporters for elder abuse. ED leaders should ensure that all providers are familiar with relevant federal, state, and local laws pertaining to elder mistreatment and their duty to report.
References and Resources
- GEMCAST: How to Identify and Intervene in Cases of Elder Abuse.
- Rosen T, Hargarten S, Flomenbaum NE, Platts-Mills TF. Identifying elder abuse in the emergency department: Toward a multidisciplinary team-based approach. Ann Emerg Med. 2016;68(3):378-82.
- Rosen T, Stern ME. Chapter 186. “Abuse and Neglect of the Older Person” in Walls R, Hockerger R, Gausche-Hill M, eds. Rosen’s Emergency Medicine: Concepts and Clinical Practice: 9th Edition, in press.
- Elder Justice Roadmap
- Lachs MS, Pillemer KA. Elder abuse. N Engl J Med. 2015;373(20):1947-1956.
- Dong XQ. Elder abuse: Systematic review and implications for practice. J Am Geriatr Soc. 2015;63(6):1214-1238.